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Overview of AHRQ Resources to Improve Patient Safety

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Title: Overview of AHRQ Resources to Improve Patient Safety


1
Overview of AHRQ Resources to Improve Patient
Safety
  • September 15, 2009

2
Agenda
  • Overview Introduction
  • Jeff Brady, M.D., AHRQ, CQuIPS
  • Speakers
  • Erin Hartman, M.S., University of California, San
    Francisco
  • Jim Battles, Ph.D., AHRQ, CQuIPS
  • Greg Maynard, M.D., University of California, San
    Diego
  • Kerm Henriksen, Ph.D., AHRQ, CQuIPS
  • Farah Englert, AHRQ, OCKT

3
To Err is Human Building a Safer Health System
  • 44,000 98,000 deaths/yr
  • 8th leading cause of death in US
  • National Costs 17 to 29 billion
  • 2 billion Adverse Rx event costs alone
  • 2 hospital admissions (preventable)
  • Add 4,700 in costs to each hospitalization

Institute of Medicine, 1999
4
Personal Experience with Medical Errors
The percentage who said they have been personally
involved in a situation where a preventable
medical error was made in their own medical care
or that of a family member?
(Source Kaiser Family Foundation surveys)
5
AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
6
Patient Safety Portfolio
  • To improve the quality of care delivered to
    patients by decreasing or eliminating health care
    risks and harms.
  • Increased emphasis on implementation
  • Continued investment in research

7
AHRQ Core Business Areas
  • Creation of Knowledge
  • Synthesis and Dissemination
  • Implementation and Use

8
AHRQ Patient Safety Budget
Projected
9
Patient Safety Portfolio Broad Areas of
Emphasis
  • Create new knowledge about safe practices and
    optimal structure for care.
  • Build research capacity by stabilizing upstream
    investment to keep the research pipeline flowing.
  • Address methodological and core scientific
    questions e.g., Evidence Report on Patient
    Safety Practices.
  • Disseminate patient safety products effectively
    for implementation.
  • Continue to engage in field-based partnerships
    (HAI ACTION)
  • Seize opportunities for national implementation
    of safe practices

10
AHRQ Patient Safety Resources
  • AHRQ PSNet
  • AHRQ WebMM
  • TeamSTEPPS Creating a safety Net for Healthcare
    Organization
  • TeamSTEPPS Rapid Response System Module
  • Hospital Survey on Patient Safety Culture
  • Hospital Survey on Patient Safety Culture 2009
    Comparative Database Report
  • Nursing Home Survey on Patient Safety Culture
  • Medical Office Survey on Patient Safety Culture
  • Preventing Hospital-Acquired Venous
    Thromboembolism A Guide for Effective Quality
    Improvement

  • Continued..

11
AHRQ Patient Safety Resources
  • Transforming Hospitals Designing for Safety and
    Quality
  • Advances in Patient Safety From Research to
    Implementation
  • Advances in Patient Safety New Directions and
    Alternative Approaches
  • Patient Safety and Quality An Evidence-Based
    Handbook for Nurses
  • Patient Safety Improvement Corps Tools, Methods,
    and Techniques for Improving Patient Safety
  • 10 Patient Safety Tips for Hospitals
  • Guide for Developing Patient Safety Councils
  • Your Guide to Preventing and Treating Blood Clots
  • Blood Thinner Pills Your Guide to Using Them
    Safely

http//www.ahrq.gov/qual/errorsix.htm
12
A world of patient safety information at your
fingertips
  • AHRQ Patient Safety Network (PSNet) and WebMM

13
AHRQ Patient Safety Network (PSNet)
  • A national one-stop portal featuring a
    collection of resources and content about
    improving patient safety and preventing medical
    errors
  • Offers weekly updates of patient safety
    literature, news, tools, conferences, as well as
    wide variety of information on patient safety
  • Diverse users can customize the site around their
    unique interests by creating a My PSNet page
  • Web site http//psnet.ahrq.gov

psnet.ahrq.gov
14
(No Transcript)
15
Search
16
Patient Safety Primers
17
AHRQ WebMM Morbidity Mortality Rounds on the
Web
  • Online journal featuring expert analysis of real
    medical error cases, perspectives on patient
    safety, and interviews with experts
  • Users submit cases of errors anonymously
  • Continuing education credit (CME/CEU) available
  • Web site http//webmm.ahrq.gov

webmm.ahrq.gov
18
(No Transcript)
19
Evidence-based Team Training and Implementation
Toolkit
  • Set of ready-to-use materials and training
    curricula to integrate teamwork principles
  • More than 900 people have been trained as
    TeamSTEPPS trainers as of July 2009
  • Collaboration between AHRQ and Department of
    Defenses military health system

http//teamstepps.ahrq.gov/
20
TeamSTEPPS Rapid Response Module
  • Rapid Response Systems ? composed of teams of
    clinicians who bring critical care expertise to
    patients requiring immediate treatment while
    under hospital care
  • Discusses how communication and teamwork
    strategies taught via TeamSTEPPStools can work
    for Rapid Response Systems
  • CD includes
  • PowerPoint presentations
  • Teaching modules
  • Video vignettes

AHRQ Publication No. 08(09)-0074-CD.
21
AHRQ Suite of Patient Safety Culture Survey Tools
  • Suite of tools that measure patient safety
    culture in
  • Hospitals
  • Medical offices
  • Nursing homes
  • Tools include survey instruments and report
    templates
  • User's Guide provides information on
  • Getting started
  • Selecting a sample
  • Determining data collection methods
  • Establishing data collection procedures
  • Conducting a Web-based survey
  • Preparing and analyzing data
  • Producing reports

22
Hospital Survey on Patient Safety Culture
  • Helps hospitals and health systems evaluate
    employee attitudes about patient safety in their
    facilities or within specific units
  • Includes survey guide, survey, and feedback
    report template to customize reports
  • AHRQ partnership with Premier, Inc., Department
    of Defense, and American Hospital Association
  • http//www.ahrq.gov/qual/hospculture/ or e-mail
    to ahrqpubs_at_ahrq.gov

23
Hospital Culture Survey Comparative Database
  • Provides results hospitals can use as benchmarks
    in establishing a patient safety culture.
  • Features a narrative description of the survey
    findings, with results by hospital and respondent
    characteristics, as well as trending results for
    98 hospitals that submitted data from previous
    and most recent safety culture surveys.
  • Appendixes provide data tables and show trends
    over time.

24
Nursing Home Survey on Patient Safety Culture
  • Pilot tested in 40 nursing homes
  • Survey materials and technical assistance for
    survey administration are free  
  • Use the survey to
  • Capture opinions of staff at all
    levels
  • Assess 12 domains of patient
    safety culture
  • Benchmark and evaluate
    patient safety efforts
  • Track changes in patient
    safety culture over time

25
Medical Office Survey On Patient Safety Culture
  • Pilot tested in 200 offices
  • Free survey materials and technical assistance
    for survey administration
  • Designed for providers and staff in
    medical offices
  • Includes about 50 items in 12 areas
    (e.g.Teamwork, Staff Training)
  • Tracks changes in patient safety and
    evaluate interventions over time

26
Guide Available for Deep Vein Thrombosis
  • Developed from Partnerships in Implementing
    Patient Safety program toolkit
  • Based on quality improvement initiatives
    undertaken at the University of California, San
    Diego Medical Center and Emory University
    Hospitals
  • Assists quality improvement practitioners in
    preventing one of the most important problems
    facing hospitalized patients - DVT / PE (VTE)

http//www.ahrq.gov/qual/vtguide/
27
Why build a toolkit for VTE Prevention?
  • VTE is a common source of inpatient MM
  • Jumbo jet crash / day- gt Breast CA, HIV, MVA
    combined
  • May be 1 preventable source of hospital death
  • Effective and safe methods of prevention exist
  • Large implementation gap - best practice ?
    current practice
  • These methods are grossly underutilized
  • Awareness, difficulty implementing, no validated
    risk assessment
  • P4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008133381S-453S. Cohen
, Tapson, Bergmann, et al. ENDORSE study Lancet
2008 371 38794. Surgeon Generals Call to
Action to Prevent DVT and PE 2008 DHHS
28
To Achieve Improvement
  • Real institutional support / prioritization
  • Will to standardize
  • Physician leadership
  • Measurement of process / outcomes
  • Protocol, integrated into order sets
  • Education
  • Continued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention
29
Hierarchy of Reliability
Predicted Prophylaxis rate
Level
  • No protocol (State of Nature)
  • Decision support exists but not linked to order
    writing, or prompts within orders but no decision
    support
  • Protocol well-integrated
  • (into orders at point-of-care)
  • Protocol enhanced
  • (by other QI / high reliability strategies)
  • Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
30
The Essential First Intervention
VTE Protocol
  • 1) a standardized VTE risk assessment, linked to
  • 2) a menu of appropriate prophylaxis options,
    plus
  • 3) a list of contraindications to pharmacologic
    VTE prophylaxis
  • Challenges
  • Make it easy to use (automatic)
  • Make sure it captures almost all patients
  • Trade-off between guidance and ease of use /
    efficiency

30
31
Low Medium
High
Example from UCSD Keep it Simple A 3 bucket
model
31
IPC needed if contraindication to AC exists
32
Map to Reach Level 3Implementing an Effective
VTE Prevention Protocol
  • Examine existing admit, transfer, periop order
    sets with reference to VTE prophylaxis.
  • Design a protocol-driven DVT prophylaxis order
    set (w/ integrated risk assessment)
  • Vette / Pilot PDSA
  • Educate / consensus building
  • Place new standardized DVT order set module
    into all pertinent admit, transfer, periop order
    sets.
  • Monitor, tweak - PDSA

33
N 2,944 mean 82 audits / month
In press, JHM 2009
In press, Maynard, Morris et al, J Hosp Med
Real time ID intervention
Order Set Implementation Adjustment
Consensus building
Baseline
33
34
34
35
Hierarchy of Reliability
Predicted Prophylaxis rate
Level
  • No protocol (State of Nature)
  • Decision support exists but not linked to order
    writing, or prompts within orders but no decision
    support
  • Protocol well-integrated
  • (into orders at point-of-care)
  • Protocol enhanced
  • (by other QI / high reliability strategies)
  • Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
36
Map to Reach Level 595 prophylaxis
  • Use MAR or Automated Reports to Classify all
    patients on the Unit as being in one of three
    zones
  • GREEN ZONE - on anticoagulation
  • YELLOW ZONE - on mechanical prophylaxis only
  • RED ZONE on no prophylaxis
  • Act to move patients out of the RED!

37
Situational Awareness and Measure-vention
Getting to Level 5
  • Identify patients on no anticoagulation
  • Empower nurses to place SCDs in patients on no
    prophylaxis as standing order (if no
    contraindications)
  • Contact MD if no anticoagulant in place and no
    obvious contraindication
  • Templated note, text page, etc
  • Need Administration to back up these
    interventions and make it clear that docs can not
    shoot the messenger

38
Collaborative Efforts and Kudos
  • SHM VTE Prevention Collaborative I - 25 sites
  • SHM / VA Pilot Group - 6 sites
  • SHM / Cerner Pilot Group 6 sites
  • AHRQ / QIO (NY, IL, IA) - 60 sites
  • IHI Expedition to Prevent VTE 60 sites
  • SHM Team Improvement Award
  • NAPH Safety Net Award
  • Venous Disease Coalition

39
AHRQ Simulation Grants
  • For research in 2007/2008 AHRQ sponsored 19
    simulation grants for more than 10 million
  • 2-year cooperative agreements
  • Focused on practitioners and teams in a variety
    of clinical settings using a diverse range of
    simulation techniques
  • Intent was to inform researchers, providers,
    health educators, patients, policy makers,
    payers, and the public

40
AHRQs Grants - A Diverse Range of Simulated
Clinical Applications
  • Central venous catheter insertion
  • High volume ambulatory surgical procedures
  • Diagnosis of melanoma
  • Obstetric emergency response drills in rural
    hospitals
  • Disclosure of medical error
  • Improving teamwork culture of safety
  • Patient-tracking systems in the emergency
    department
  • Acute coronary syndrome management in rural
    setting
  • Medication administration
  • Rapid response emergency team training
  • Management of acute care events by graduate
    physicians
  • Airway management in the pediatric intensive care
    unit
  • Training rapid response teams
  • Emergent cesarean deliveries
  • Three-dimensional virtual reality team training
  • Patient care hand-offs
  • Postanesthesia care unit communication
  • Pediatric emergency care
  • Resuscitation team response in small rural
    hospitals

41
Evidence Based Design
  • Build Private Rooms
  • Reduce Noise
  • Incorporate Nature
  • Improve Air Quality
  • Encourage Hand Hygiene
  • Improve Wayfinding
  • Reduce Walking Distance

42
Transforming Hospitals Designing for Safety and
Quality
  • A DVD that demonstrates how evidence-based design
    can improve the quality and safety of hospital
    services while improving staff satisfaction and
    retention
  • Case studies of three hospitals illustrate the
    benefit of incorporating evidence-based design
    principles into new construction or renovation
    projects

AHRQ Publication No. 07-0076-DVD
43
Advances in Patient Safety From Research to
Implementation
  • Four-volume set of 140 peer-reviewed articles
    representing an overview of patient safety studies

AHRQ Publication No. 05-0021-CD
44

Advances in Patient Safety New Directions and
Alternative Approaches
  • Describes new patient safety findings,
    investigative approaches, process analyses,
    lessons learned, and practical tools to prevent
    harming patients
  • 4-volume set or 1 CD of 115 articles on reporting
    systems, risk assessment, safety culture, medical
    simulation, patient safety tools and practices,
    health information technology, medication safety,
    and more

AHRQ Publication No. 08-0034 (print copy) or
08-0034-CD (Searchable CD-ROM)
45
Handbook for Nurses
  • Comprehensive, 1400-page handbook for nurses on
    patient safety and quality.
  • Experts in the field reviewed the literature, and
    their contributions are grouped into sections
    that address
  • Patient safety and quality
  • Evidence-based practice
  • Patient-centered care
  • Working conditionswork environment
  • Critical opportunities for patient safety and
    quality
  • Tools

AHRQ Publication No. 08-0043 (print copy) or
08-0043-CD (CD-ROM)
46
Patient Safety Improvement Corps
  • DVD features a self-paced, modular approach to
    training individuals involved in patient safety
    activities at the institutional level.
  • Modules address
  • Investigation of medical errors and their root
    causes.
  • Identification, implementation, and evaluation of
    system-level interventions to address patient
    safety concerns.
  • Steps necessary to promote a culture of safety
    within a hospital or other health care facility.

AHRQ Publication No. 07-0035-DVD
47
10 Patient Safety Tips for Hospitals
  • Evidence-based tips help hospitals promote
    patient safety
  • Go to http//www.ahrq.gov/qual/10tips.pdf

48
Guide for Developing Patient Safety Councils
  • Provides information and guidance to empower
    individuals and organizations to develop a
    community-based advisory council
  • Councils involve patients, consumers, and a
    variety of practitioners and professionals from
    health care and community organizations
  • Councils drive change for patient safety through
    education, collaboration, and consumer engagement

http//www.ahrq.gov/qual/advisorycouncil/
49
Blood Clot Prevention
  • Deep vein thrombosis is a potentially deadly
    medical problem that affects at least 350,000 and
    possibly as many as 600,000 Americans each year
  • 24-page easy-to-read booklet in English and
    Spanish that helps both patients and their
    families
  • Identify the causes and symptoms of dangerous
    blood clots.
  • Learn tips on how to prevent them.
  • Know what to expect during treatment.
  • Created by experts funded through AHRQ's
    Partnerships in Implementing Patient Safety grant
    program

http//www.ahrq.gov/consumer/bloodclots.htm
50
Blood Thinner Pills Your Guide to Using Them
Safely
  • Consumer publication and DVD explain what to
    expect and watch out for while taking blood
    thinner pills
  • Based on research originally conducted by one of
    AHRQs Partnership for Implementing Patient
    Safety grant projects
  • Educates patients about
  • Medication therapy and potential side
    effects
  • How to communicate effectively with their health
    care providers
  • Tips for lifestyle modifications

http//www.ahrq.gov/consumer/btpills.htm
51
How to Order?
  • Ordering information for AHRQ Publications
    Products available at
  • http//www.ahrq.gov/news/pubsix.htm

Call the AHRQ Publication Clearinghouse at
1-800-358-9295 Send an email to
AHRQPubs_at_ahrq.hhs.gov
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